Missed Follow-up Appointments Linked to Worse Survival in Stage 1 Lung Cancer Patients

A recent study highlighting the association between missed follow-up appointments and an increased risk of death in people diagnosed with stage I non-small cell lung cancer, was published July 2024 in Scientific Reports.

Conducted by Jordan A. Holmes, M.D., M.P.H., and colleagues at Indiana University, the study was an attempt to understand the relationship between follow-up care adherence and overall survival, the researchers analyzed data from patient records.

The analysis included adults diagnosed with stage I non-small cell lung cancer at the Indiana University hospital network between 2007 and 2016. The study excluded patients whose records were missing demographic information or had only one appointment scheduled, and those who did not survive for at least one year following diagnosis. The researchers defined a missed appointment as an unattended follow-up visit within a year after diagnosis without an attended appointment within the next 60 days.

Among the analyzed cohort of 582 patients, the median age was 69, with the majority covered by Medicare, and the average follow-up was 3.2 years. Most patients underwent surgical treatment for stage I lung cancer. Overall, patient adherence to follow-up appointments was relatively high. Each patient had between 2 and 58 appointments, with a median of 4. Missed follow-up visits ranged from 0 to 4, averaging 0.4 missed visits per patient.

However, the results of the multivariable analysis showed that, after accounting for various demographic and other factors, each 10% increase in missed appointments was associated with a 44% increase in the risk of death. Factors such as transportation issues, financial constraints, and general inconvenience were cited as common reasons for missed appointments.

"When lung cancer comes back, it’s often not curable," Andrew Hertler, M.D., chief medical officer at Evolent in Arlington, Virginia, who was not involved in the study, told MHE in an interview. While Hertler acknowledged the association, he emphasized that an association does not suggest causation.

“I don't believe missing appointments is likely to be a cause of increased mortality in these patients with lung cancer,” he said. “I suspect that they're missing appointments because they're sick, or they have difficulties with transportation because they're elderly or have economic or other challenges.”

Furthermore, Hertler explained that these follow-up visits include general screening, such as scanning tests and symptom checks. “While it’s not good to miss these appointments, there aren’t necessarily interventions done that are specifically going to prevent recurrence,” he said.

Hertler also noted a limitation, as did the authors in their paper, that the studied healthcare system is a tertiary referral center, and its location may be inconvenient for some patients. He compared the association to a chicken-or-egg-first scenario— “Are we seeing increased mortality because of missed appointments, or are missed appointments happening because some people are too sick to travel to an institution that may be further from home?”

Lung cancer remains a leading cause of cancer-related deaths in the United States. As such, more research is needed to identify interventions that could overcome barriers to patient attendance at follow-up visits.